High-risk cardiac surgery: Time to explore a new paradigm

The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery

“…The TandemHeart is an external temporary device based on the insertion of a cannula (21-Fr cannula) through the interatrial septum to the left atrium. It is composed of three subsystems (a transseptal cannula, the centrifugal blood pump, and an arterial cannula) [ 8 , 39 ]. Oxygenated blood is pumped out from the left atrium to a centrifugal pump which continuously returns the blood to the femoral artery through a 12 Fr cannula or to the iliac artery through a 5–17 Fr cannula ( Figure 2 ).…”

“…Oxygenated blood is pumped out from the left atrium to a centrifugal pump which continuously returns the blood to the femoral artery through a 12 Fr cannula or to the iliac artery through a 5–17 Fr cannula ( Figure 2 ). This device is capable of generating a continuous flow of up to 4 L/min output [ 8 , 39 ]. Moreover, the addition of an oxygenator makes it possible for respiratory support [ 64 ].…”

Commentary: Preemptive left ventricular unloading in high-risk cardiac operations—uncertain risk/benefit relationships, but promising!

“…Goldstein and Soltesz 1 present a preliminary report on the use of the advanced Impella support device (Impella version 5.5; Abiomed, Danvers, Mass) for preemptive ventricular support in high-risk patients undergoing operation in the setting of significant ventricular compromise. When preexisting stunned, hibernating, and/or acutely ischemic myocardium is subjected to the pathophysiology of the cardiopulmonary bypass circuit, to the ischemia mandated by crossclamping, and to the possibility of suboptimal cardioprotection, the result is often a dangerous combination of vasoplegia and postoperative low cardiac output.…”

“…Other rather extreme measures like left ventricular assist devices and transplantation are final steps in this decision algorithm and these are even less likely to provide a satisfactory outcome in the urgent setting of low cardiac output and severe left ventricular dysfunction after operation. In response to postcardiotomy shock, Goldstein and Soltesz 1 present an intriguing option: The paradigm of preventive support with preemptive ventricular unloading.…”

“…Further, the conduct of a randomized trial to test the effectiveness of the Impella device as a prophylactic intervention would be a statistical design nightmare clouded with ethical issues and uncertain indications for use. Goldstein and Soltesz 1 are aware of these issues and acknowledge that the published experience with the Impella device is limited to 2 reports that studied a cohort of slightly more than 200 patients, nearly all of whom did not have device insertion for prophylactic purposes.…”